Trans-Oral Incisionless Fundoplication (TIF): How I Do It and Why

2021 ◽  
pp. 263451612110249
Author(s):  
Kenneth J. Chang
Keyword(s):  
Hernia Repair ◽  
Lower Esophageal Sphincter ◽  
Treatment Option ◽  
Structure And Function ◽  
Transoral Incisionless Fundoplication ◽  
Standardized Protocol ◽  
Esophageal Sphincter ◽  
And Function ◽  
Flap Valve

Transoral Incisionless Fundoplication (TIF) is designed to create a 3 cm length, 270° to 300°, omega-shaped flap valve, reconstructing the structure and function of the lower esophageal sphincter (LES), including the gastric sling fibers. As such, TIF is a treatment option for GERD patients with an intact crura, but have lost the integrity and function of the LES. In patients requiring a hernia repair, TIF can be used concomitantly (cTIF). While there are a number of steps to the TIF 2.0 procedure, many of the sequences are repetitive and follow a standardized protocol, optimizing efficiency, safety, and scalability.

Inhibition of transient lower esophageal sphincter relaxations by electrical acupoint stimulation

2005 ◽  
Vol 289 (2) ◽  
pp. G197-G201 ◽  
Author(s):  
Duowu Zou ◽  
Wei Hao Chen ◽  
Katsuhiko Iwakiri ◽  
Rachael Rigda ◽  
Marcus Tippett ◽  
...  
Keyword(s):  
Healthy Volunteers ◽  
Lower Esophageal Sphincter ◽  
Gastrointestinal Symptoms ◽  
Endogenous Opioids ◽  
Gastric Distension ◽  
Gastric Distention ◽  
Upper Gastrointestinal Symptoms ◽  
Esophageal Sphincter ◽  
And Function ◽  
Acupoint Stimulation

Acupuncture has been shown to modulate visceral sensation and function. Traditionally, stimulation at the Neiguan (pericardial meridian) has been used to treat upper gastrointestinal symptoms. Some of the effects of acupuncture may be mediated through release of endogenous opioids and are reversed by naloxone. Gastric distension is the major trigger for transient lower esophageal sphincter (LES) relaxations (TLESRs). The aim of this study was to investigate the effect of electric stimulation at the Neiguan and naloxone on the TLESRs. In 14 healthy volunteers, electrical acupoint stimulation was applied at the Neiguan and a sham point on the hip in randomized order on the same day. In 12 healthy volunteers, the effects of naloxone (80 μg/kg iv bolus injection) and saline on electrical acupoint stimulation were compared on separate days at least 1 wk apart. Esophageal motility was measured during distension of the proximal stomach with 500 ml of air using a barostat balloon. Electric acupoint stimulation at the Neiguan decreased the rate of TLESRs by ∼40% from a median of 6/h to 3.5/h ( P < 0.02). Acupoint stimulation had no effect on basal LES pressure, the residual LES pressure during TLESRs, the duration of TLESRs, or gastrointestinal symptoms of fullness, bloating, discomfort, or nausea. The effect of acupoint stimulation was not inhibited by naloxone. Electric acupoint stimulation at the Neiguan significantly inhibits the frequency of TLESRs in response to gastric distention in healthy subjects. This effect does not appear to be mediated through μ-opioid receptors.

scholarly journals Circular and longitudinal muscles shortening indicates sliding patterns during peristalsis and transient lower esophageal sphincter relaxation

2015 ◽  
Vol 309 (5) ◽  
pp. G360-G367 ◽  
Author(s):  
Nirali Patel ◽  
Yanfen Jiang ◽  
Ravinder K. Mittal ◽  
Tae Ho Kim ◽  
Melissa Ledgerwood ◽  
...  
Keyword(s):  
Lower Esophageal Sphincter ◽  
Animal Studies ◽  
Longitudinal Muscle ◽  
Circular Muscle ◽  
Esophageal Sphincter ◽  
And Function ◽  
Longitudinal Muscles ◽  
Histology And Immunohistochemistry ◽  
Esophageal Contraction ◽  
Axial Shortening

Esophageal axial shortening is caused by longitudinal muscle (LM) contraction, but circular muscle (CM) may also contribute to axial shortening because of its spiral morphology. The goal of our study was to show patterns of contraction of CM and LM layers during peristalsis and transient lower esophageal sphincter (LES) relaxation (TLESR). In rats, esophageal and LES morphology was assessed by histology and immunohistochemistry, and function with the use of piezo-electric crystals and manometry. Electrical stimulation of the vagus nerve was used to induce esophageal contractions. In 18 healthy subjects, manometry and high frequency intraluminal ultrasound imaging during swallow-induced esophageal contractions and TLESR were evaluated. CM and LM thicknesses were measured (40 swallows and 30 TLESRs) as markers of axial shortening, before and at peak contraction, as well as during TLESRs. Animal studies revealed muscular connections between the LM and CM layers of the LES but not in the esophagus. During vagal stimulated esophageal contraction there was relative movement between the LM and CM. Human studies show that LM-to-CM (LM/CM) thickness ratio at baseline was 1. At the peak of swallow-induced contraction LM/CM ratio decreased significantly (<1), whereas the reverse was the case during TLESR (>2). The pattern of contraction of CM and LM suggests sliding of the two muscles. Furthermore, the sliding patterns are in the opposite direction during peristalsis and TLESR.

scholarly journals Atypical Manometric Abnormality of the Lower Esophageal Sphincter: A Procedure-Related, Stress-Induced Phenomenon?

1995 ◽  
Vol 9 (6) ◽  
pp. 349-351 ◽  
Author(s):  
Bhuvanendram Indrakrishnan ◽  
William G Paterson
Keyword(s):  
Lower Esophageal Sphincter ◽  
Initial Study ◽  
Esophageal Sphincter ◽  
Related Stress ◽  
And Function ◽  
Esophageal Contraction

Stress-induced esophageal contraction abnormalities have been well documented in the literature, but relatively little is known about stress-related lower esophageal sphincter (LES) dysfunction. Two patients are described in whom initial manometry studies revealed LES hypertension and impaired LES relaxation. Both patients were markedly anxious and agitated during the initial study. However, when the manometry was repeated with the patients in a calmer state, LES pressure and function were normal. These cases demonstrate the need to be aware of stress-related LES dysfunction. If this phenomenon is not identified in the appropriate settings, it could lead to significant errors in management.

Impaired platelet-derived growth factor receptor expression and function in cultured lower esophageal sphincter circular smooth muscle cells from W/Wv mutant mice

2014 ◽  
Vol 92 (1) ◽  
pp. 34-41 ◽  
Author(s):  
Francisco Bautista-Cruz ◽  
Dileep G. Nair ◽  
Sandra Lourenssen ◽  
David V. Miller ◽  
Michael G. Blennerhassett ◽  
...  
Keyword(s):  
Smooth Muscle ◽  
Growth Factor ◽  
Lower Esophageal Sphincter ◽  
Mutant Mice ◽  
Platelet Derived Growth Factor ◽  
Wild Type ◽  
Rt Pcr ◽  
Circular Smooth Muscle ◽  
Esophageal Sphincter ◽  
And Function

We have previously demonstrated that lower esophageal sphincter (LES) circular smooth muscle (CSM) is functionally impaired in W/Wv mutant mice that lack interstitial cells of Cajal, and speculated that this could be due to altered smooth muscle differentiation. Platelet-derived growth factor (PDGF) is involved in the maturation and differentiation of smooth muscle. To determine whether PDGF expression and (or) function is altered in W/Wv mutant mice, PDGF-Rβ expression was measured using RT-PCR, qPCR, and immunocytochemistry, and Ca2+ imaging and perforated patch clamp recordings performed in isolated LES CSM cells. RT-PCR and immunocytochemistry showed significantly reduced PDGF-Rβ expression in the LES from mutant as opposed to wild-type mice. Quantitative comparison of CSM cell numbers in histological specimens revealed a significantly increased average cell size in the mutant tissue. The specific PDGF-Rβ ligand, PDGF-BB, caused a significant increase in intracellular Ca2+ in cells from the wild-type mice compared with the mutants. Using a ramp protocol, PDGF-BB caused a 2-fold increase in outward K+ currents in cells from the wild-type mice, whereas no significant increase was measured in the cells from the mutants. We conclude that the expression and function of PDGF-Rβ in LES CSM from W/Wv mice is impaired, providing further evidence that LES CSM is abnormal in W/Wv mutants.

The Benefits of Nonablative Radiofrequency Treatment of the Lower Esophageal Sphincter After Transoral Incisionless Fundoplication

2020 ◽  
Vol 86 (11) ◽  
pp. 1525-1527
Author(s):  
Medhat Fanous ◽  
Anja Jaehne ◽  
Jenna Simbob
Keyword(s):  
Hiatal Hernia ◽  
Lower Esophageal Sphincter ◽  
Transoral Incisionless Fundoplication ◽  
Gradual Improvement ◽  
Hrql Score ◽  
Demeester Score ◽  
Radiofrequency Treatment ◽  
Patient Reported ◽  
Sliding Hiatal Hernia ◽  
Esophageal Sphincter

Non-ablative radiofrequency treatment to the lower esophageal sphincter (Stretta) has been shown to be beneficial after failed Nissen fundoplication. To our knowledge, this is the first report of Stretta after transoral incisionless fundoplication (TIF). This patient is a 17-year-old female who had gastroesophageal reflux disease (GERD) symptoms for 9 years. She presented with heartburn, regurgitation, and epigastric discomfort. She used omeprazole for 9 years. Esophagogastroduodenoscopy (EGD) showed a 2 cm sliding hiatal hernia and DeMeester score of 25. The GERD Health-Related Quality of Life (GERD-HRQL) score on omeprazole was 14. Patient underwent a TIF procedure, which was uneventful. Her symptoms resolved, and she discontinued omeprazole. Six months later, she had episodes of repeated violent vomiting followed by recurrence of regurgitation, nausea, bloating, and dysphagia. She resumed omeprazole. Diagnostic workup included gastric emptying scan, which was normal. EGD showed no hiatal hernia and partial disruption of the TIF valve. DeMeester score was 36.3. Esophageal manometry with impedance showed intact peristalsis and normal relaxation of the lower esophageal sphincter. The patient underwent Stretta, which was uneventful. The previous TIF did not increase the complexity of the procedure. There were no immediate or postoperative complications. The patient reported gradual improvement of her symptoms with complete resolution 2 months postoperatively. She discontinued omeprazole. The GERD-HRQL score 17 months post-Stretta was 0. This case highlights the feasibility, safety, and efficacy of performing Stretta following TIF. It provides an endoluminal alternative to complex revisional antireflux surgery. Prospective studies with longer follow-up are required to validate this concept.

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